Provider Demographics
NPI:1750861480
Name:WELLS, SHANTELLE M
Entity Type:Individual
Prefix:MS
First Name:SHANTELLE
Middle Name:M
Last Name:WELLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 SE ROSE GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-2802
Mailing Address - Country:US
Mailing Address - Phone:816-878-3945
Mailing Address - Fax:
Practice Address - Street 1:3801 BLUE PKWY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64130-2807
Practice Address - Country:US
Practice Address - Phone:816-599-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018027693101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional